Community Services Strategy: Survival analysis

Author

Sarah Lucas

Published

2025-01-06

Aims

This analysis aims to investigate the risk of death or subsequent readmission in patients who have had an emergency hospital admission. It will help us understand what factors influence the risk of death or readmission, including determining variability between ICB area. This could help identify where activity might be mitigated through appropriate community services provision.

Methodology

Three patient cohorts are included within this analysis:

  • Elderly emergency: those 75 or over with an emergency admission.

  • Frail: those 65 or over with an emergency admission and a frailty score over 5. The frailty score is calculated from ICD-10 diagnoses recorded for admissions during the previous 2 years and using the risk scores in Gilbert et al (2018), Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study. The Lancet, 391(10132), pp.1775-1782. (Note these patients are a subset for those in the elderly emergency cohort)

  • Falls: those 65 or over with an emergency admission related to a fall.

The End of life cohort are not included as by definition they die during their hospital admission.

Survival analysis has been conducted using data from 2023/23 for

  • Time to death (mortality)

  • Time to readmission (time to readmission from the first admission for all patients including some that will have died in the year post-admission)

  • Time to readmission- excluding those who died prior to readmission

Note: Frimley ICB has been removed from the analysis due to missing data.

Mortality

The time from when a patient first had an emergency admission and first entered the cohort until death was calculated. Those who died on the same day as their emergency admission when they first entered the cohort were excluded.

Summary of percentage of patients dying within 1 year (2022/23)

Elderly Emergency

Frail

Falls

Sex

female

153,304 (27.6%)

116,885 (27.2%)

19,988 (21.5%)

male

144,597 (32.6%)

116,496 (31.2%)

14,267 (30.9%)

Age

60-64

N/A

N/A

144 (8.5%)

65-69

N/A

16,436 (16.8%)

1,003 (10.2%)

70-74

N/A

27,103 (20%)

2,302 (13.8%)

75-79

66,638 (21.1%)

37,385 (23.9%)

4,156 (17.7%)

80-84

77,711 (26.7%)

48,410 (29.6%)

6,941 (23.3%)

85-89

81,698 (34.5%)

53,965 (36.9%)

9,322 (29.1%)

90+

71,854 (46.6%)

50,082 (48.5%)

10,387 (40.4%)

Ethnicity

Asian/Asian British

6,250 (24.4%)

5,251 (22.6%)

485 (19.4%)

Black/Black British

3,127 (25.6%)

2,480 (25%)

229 (19.6%)

Mixed

637 (25.7%)

562 (25.6%)

65 (21.9%)

Other

2,997 (27.1%)

2,440 (25.1%)

315 (19.9%)

White British

246,628 (30.2%)

192,855 (29.6%)

28,761 (25.2%)

White Other

9,929 (28.9%)

7,831 (28.1%)

1,169 (23.1%)

Unknown

28,333 (29.3%)

21,962 (27.5%)

3,231 (22.4%)

IMD decile

1

24,999 (32.1%)

22,026 (30.2%)

2,925 (25.5%)

2

26,503 (31.7%)

22,394 (30.3%)

3,248 (25.7%)

3

26,973 (30.9%)

22,154 (29.6%)

3,250 (25.4%)

4

29,863 (31%)

23,434 (29.8%)

3,346 (24.9%)

5

31,003 (30.1%)

24,284 (29.4%)

3,509 (24.5%)

6

32,350 (29.6%)

24,619 (28.8%)

3,720 (24.6%)

7

32,695 (29.4%)

24,828 (28.8%)

3,681 (24.5%)

8

32,454 (28.9%)

24,659 (28.6%)

3,625 (24%)

9

31,686 (28.4%)

23,624 (27.9%)

3,677 (24.3%)

10

29,375 (27.8%)

21,359 (27.3%)

3,274 (23.2%)

Total

297,901 (29.8%)

233,381 (29%)

34,255 (24.6%)

Comparing time to death between the cohorts using Kaplan-meier plot (2022/23)

For those first admitted in 2022/23 we considered the time to death from when the person was first admitted. The most recent year 2023/2024 was not used as there has not be sufficient time for those that entered the cohort at the end of this year to have a full year of follow-up time.

The risk of death is highest in the frail cohort, followed by the elderly emergency cohort, with those in the falls cohort have a lowest risk of death.

Kaplan Meier survival plots of time to death (2022/23)

Summary

The risk of death is increased:

  • with age

  • in males

  • with increasing deprivation

  • in those who are White British, compared to all other those of other ethnicities

There is some variation between ICBs in the risk of death with the lowest risk seen in the North West London ICB area.


ICB

Deaths

No. at risk

Percentage

QRV: NHS North West London ICB

6,849

27,484

24.9

QUY: NHS Bristol, N S'set & S Gloucs ICB

4,666

16,818

27.7

QRL: NHS Hampshire And Isle Of Wight ICB

10,666

38,428

27.8

QHL: NHS Birmingham And Solihull ICB

6,382

22,495

28.4

QMJ: NHS North Central London ICB

4,193

14,789

28.4

QOX: NHS Bath & NE S'set, S'don & W ICB

4,858

17,130

28.4

QK1: NHS Leics, Leic'shire & Rutland ICB

5,067

17,771

28.5

QNC: NHS Staffordshire & Stoke-On-Tr ICB

6,912

24,269

28.5

QU9: NHS Bucks, Oxford & Berkshire W ICB

7,984

28,049

28.5

QXU: NHS Surrey Heartlands ICB

5,986

20,998

28.5

QVV: NHS Dorset ICB

5,714

19,896

28.7

QOC: NHS Shrops, Telford & Wrekin ICB

2,968

10,293

28.8

QJK: NHS Devon ICB

7,844

26,939

29.1

QKS: NHS Kent And Medway ICB

10,060

34,471

29.2

QKK: NHS South East London ICB

6,225

21,259

29.3

QMF: NHS North East London ICB

5,466

18,643

29.3

QWE: NHS South West London ICB

5,427

18,500

29.3

QR1: NHS Gloucestershire ICB

3,313

11,237

29.5

QT6: NHS Cornwall & Isles Of Scilly ICB

2,928

9,939

29.5

QSL: NHS Somerset ICB

4,061

13,732

29.6

QNX: NHS Sussex ICB

10,862

36,457

29.8

QWU: NHS Coventry And Warwickshire ICB

5,415

18,159

29.8

QHM: NHS North East & North Cumbria ICB

19,714

65,902

29.9

QUA: NHS Black Country ICB

7,396

24,576

30.1

QHG: NHS Beds, Luton & Milton Keynes ICB

4,501

14,927

30.2

QYG: NHS Cheshire And Merseyside ICB

15,278

50,607

30.2

QM7: NHS Hertfordshire & West Essex ICB

8,061

26,636

30.3

QJ2: NHS Derby And Derbyshire ICB

6,637

21,849

30.4

QF7: NHS South Yorkshire ICB

8,407

27,379

30.7

QPM: NHS Northamptonshire ICB

4,008

13,051

30.7

QE1: NHS Lancashire & South Cumbria ICB

10,652

34,591

30.8

QH8: NHS Mid And South Essex ICB

7,208

23,207

31.1

QJM: NHS Lincolnshire ICB

4,941

15,888

31.1

QJG: NHS Suffolk & North East Essex ICB

6,632

21,272

31.2

QOQ: NHS Humber And North Yorkshire ICB

11,283

36,146

31.2

QUE: NHS Cambs & Peterborough ICB

4,836

15,406

31.4

QGH: NHS Herefords & Worcestershire ICB

4,710

14,967

31.5

QOP: NHS Greater Manchester ICB

14,402

45,513

31.6

QT1: NHS Nott'ham & Nottinghamshire ICB

6,366

20,151

31.6

QWO: NHS West Yorkshire ICB

12,349

38,283

32.3

QMM: NHS Norfolk And Waveney ICB

7,314

22,419

32.6

Summary

The risk of death is increased:

  • with age

  • in males

  • with increasing deprivation

  • in those who are White British, compared to all other those of other ethnicities

There is some variation between ICBs in the risk of death, with many of the London ICB areas having a lower risk of death.


ICB

Deaths

No. at risk

Percentage

QT6: NHS Cornwall & Isles Of Scilly ICB

229

1,200

19.1

QMJ: NHS North Central London ICB

503

2,542

19.8

QRV: NHS North West London ICB

847

4,079

20.8

QOX: NHS Bath & NE S'set, S'don & W ICB

543

2,486

21.8

QOC: NHS Shrops, Telford & Wrekin ICB

283

1,290

21.9

QU9: NHS Bucks, Oxford & Berkshire W ICB

844

3,757

22.5

QKS: NHS Kent And Medway ICB

755

3,310

22.8

QWE: NHS South West London ICB

660

2,891

22.8

QNX: NHS Sussex ICB

1,254

5,485

22.9

QRL: NHS Hampshire And Isle Of Wight ICB

1,391

6,055

23.0

QNC: NHS Staffordshire & Stoke-On-Tr ICB

645

2,751

23.4

QXU: NHS Surrey Heartlands ICB

676

2,867

23.6

QKK: NHS South East London ICB

987

4,166

23.7

QJK: NHS Devon ICB

767

3,206

23.9

QVV: NHS Dorset ICB

636

2,663

23.9

QYG: NHS Cheshire And Merseyside ICB

1,607

6,722

23.9

QJ2: NHS Derby And Derbyshire ICB

594

2,466

24.1

QMF: NHS North East London ICB

820

3,391

24.2

QJM: NHS Lincolnshire ICB

508

2,085

24.4

QT1: NHS Nott'ham & Nottinghamshire ICB

646

2,648

24.4

QGH: NHS Herefords & Worcestershire ICB

531

2,159

24.6

QHM: NHS North East & North Cumbria ICB

2,203

8,901

24.8

QUE: NHS Cambs & Peterborough ICB

560

2,257

24.8

QSL: NHS Somerset ICB

467

1,859

25.1

QE1: NHS Lancashire & South Cumbria ICB

1,241

4,927

25.2

QJG: NHS Suffolk & North East Essex ICB

747

2,949

25.3

QM7: NHS Hertfordshire & West Essex ICB

983

3,867

25.4

QPM: NHS Northamptonshire ICB

468

1,844

25.4

QHL: NHS Birmingham And Solihull ICB

715

2,804

25.5

QWU: NHS Coventry And Warwickshire ICB

654

2,539

25.8

QK1: NHS Leics, Leic'shire & Rutland ICB

600

2,319

25.9

QOP: NHS Greater Manchester ICB

1,653

6,377

25.9

QHG: NHS Beds, Luton & Milton Keynes ICB

639

2,426

26.3

QOQ: NHS Humber And North Yorkshire ICB

1,165

4,417

26.4

QWO: NHS West Yorkshire ICB

1,470

5,489

26.8

QMM: NHS Norfolk And Waveney ICB

910

3,378

26.9

QR1: NHS Gloucestershire ICB

414

1,523

27.2

QF7: NHS South Yorkshire ICB

1,017

3,728

27.3

QUY: NHS Bristol, N S'set & S Gloucs ICB

702

2,570

27.3

QUA: NHS Black Country ICB

966

3,524

27.4

QH8: NHS Mid And South Essex ICB

1,046

3,650

28.7

Summary

The risk of death is increased:

  • with age

  • in males

  • with increasing deprivation

  • in those who are White British, compared to all other those of other ethnicities

There is some variation between ICBs in the risk of death, with the lowest risk of death seen in the North West London ICB area.


ICB

Deaths

No. at risk

Percentage

QRV: NHS North West London ICB

5,644

23,660

23.9

QOX: NHS Bath & NE S'set, S'don & W ICB

3,426

12,814

26.7

QNC: NHS Staffordshire & Stoke-On-Tr ICB

5,453

20,248

26.9

QXU: NHS Surrey Heartlands ICB

4,412

16,387

26.9

QVV: NHS Dorset ICB

4,046

14,882

27.2

QHL: NHS Birmingham And Solihull ICB

5,016

18,286

27.4

QRL: NHS Hampshire And Isle Of Wight ICB

8,039

29,320

27.4

QUY: NHS Bristol, N S'set & S Gloucs ICB

3,621

13,194

27.4

QU9: NHS Bucks, Oxford & Berkshire W ICB

6,174

22,196

27.8

QMJ: NHS North Central London ICB

3,294

11,777

28.0

QK1: NHS Leics, Leic'shire & Rutland ICB

3,972

14,073

28.2

QWE: NHS South West London ICB

4,340

15,363

28.2

QOC: NHS Shrops, Telford & Wrekin ICB

2,296

8,102

28.3

QSL: NHS Somerset ICB

3,018

10,657

28.3

QT6: NHS Cornwall & Isles Of Scilly ICB

2,077

7,338

28.3

QKK: NHS South East London ICB

5,247

18,472

28.4

QHM: NHS North East & North Cumbria ICB

15,912

55,575

28.6

QR1: NHS Gloucestershire ICB

2,404

8,346

28.8

QNX: NHS Sussex ICB

8,245

28,548

28.9

QJK: NHS Devon ICB

5,759

19,884

29.0

QKS: NHS Kent And Medway ICB

7,063

24,247

29.1

QMF: NHS North East London ICB

4,559

15,668

29.1

QYG: NHS Cheshire And Merseyside ICB

12,608

43,345

29.1

QUA: NHS Black Country ICB

5,976

20,483

29.2

QHG: NHS Beds, Luton & Milton Keynes ICB

3,572

12,162

29.4

QWU: NHS Coventry And Warwickshire ICB

4,379

14,819

29.5

QF7: NHS South Yorkshire ICB

6,626

22,358

29.6

QJM: NHS Lincolnshire ICB

3,832

12,955

29.6

QM7: NHS Hertfordshire & West Essex ICB

6,185

20,929

29.6

QJ2: NHS Derby And Derbyshire ICB

5,188

17,415

29.8

QH8: NHS Mid And South Essex ICB

5,752

19,048

30.2

QE1: NHS Lancashire & South Cumbria ICB

8,626

28,270

30.5

QPM: NHS Northamptonshire ICB

3,372

11,062

30.5

QOP: NHS Greater Manchester ICB

11,827

38,669

30.6

QOQ: NHS Humber And North Yorkshire ICB

8,835

28,868

30.6

QT1: NHS Nott'ham & Nottinghamshire ICB

5,079

16,469

30.8

QWO: NHS West Yorkshire ICB

9,986

32,383

30.8

QUE: NHS Cambs & Peterborough ICB

3,866

12,459

31.0

QGH: NHS Herefords & Worcestershire ICB

3,608

11,594

31.1

QJG: NHS Suffolk & North East Essex ICB

5,113

16,212

31.5

QMM: NHS Norfolk And Waveney ICB

5,479

17,331

31.6

Multivariate survival analysis of time to death (2022/23)

For this analysis we have taken only data from 2022-2023, and only the first admission for each patient. We have excluded admissions where the person died on the day of admission.

We have fitted multivariate Cox proportional hazard models to our data to assess how various factors independently affect the risk of readmission occurring over time.

Assumptions of Cox proportional hazards models

Cox proportional hazards models assume that the hazard rate (in this case risk of death) for a person with one set of covariates is proportional to the hazard rate for a person with a different set of covariates, so that the hazard ratio is assumed to be constant over time.

The proportional hazards (PH) assumption can be checked using statistical tests and graphical diagnostics based on the scaled Schoenfeld residuals.

We find significant p-values for some covariates, particularly for ICBs, indicating that the data violates the proportional hazards assumption. This is unsurprising as we have very high number of patients included within our dataset, which means even very small deviations in the residuals over time can result in significant p-values.

Plotting a smoothed fit to the Schoenfeld residuals allows us to determine, where p-values are significant, whether the changes in the beta coefficient over time are large enough to meaningfully impact our analyses. Deviations from a horizontal line indicate non-proportional hazards, and that the hazard ratio will be changing over time.

There are alternatives when the proportional hazards assumption is violated such as adding a time interaction into the model or using an alternative accelerated failure model. With the size of our dataset and the number of covariates (over 40 ICBs) the alternatives do not appear feasible and would unlikely add useful information to our conclusions.

Considering these factors and that for this analysis the degree of variation and trends are more important than the absolute hazard ratios we have used a Cox proportional hazards models, and the calculated hazard ratios can be considered as a time-averaged hazard ratio. We have modelled the risk of death within 28 days and within 1 yr. Considering the first 28 day period alongside the 1 year time period means we can check for any initial differences in the first 28 days that might be averaged out in the long 1 year period. There are some differences in the hazard ratios calculated for the two models, but the general trends are consistent.

Elderly emergency

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex         43.1050  1 0.0000   *
age_range  141.4244  1 0.0000   *
ethnicity    0.2548  1 0.6137    
imd_decile   0.1283  1 0.7202    
icb          1.0181  1 0.3130    
GLOBAL     250.2182 59 0.0000   *

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex         36.3556  1 0.0000   *
age_range  331.1640  1 0.0000   *
ethnicity    0.0095  1 0.9225    
imd_decile   1.2292  1 0.2676    
icb          1.0411  1 0.3076    
GLOBAL     647.4959 59 0.0000   *

Summary

In the elderly emergency cohort the risk of death post-admission:

  • is higher in males.

  • increases with increasing age.

  • up to 28 days those who are Black/Black British or White Other ethnicity have a lower risk of death compared to White British, while Other and Unknown ethnicities have an increased risk. In the 1 year post-admission the risk of death is lower compared to White British for all other ethnicities, apart from Unknown.

  • increases with increasing deprivation, those living in the most deprived areas (IMD decile 1) have a higher risk of death than those living in the least deprived areas (IMD decile 10).

  • varies by ICB area. The risk of death is lowest in the North West London ICB area and highest in the Norfolk and Waveney ICB area.

Falls

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

               chisq df      p sig
sex           0.0197  1 0.8885    
age_range  2339.4301  1 0.0000   *
ethnicity     0.3180  1 0.5728    
imd_decile    0.0431  1 0.8355    
icb          97.5354  1 0.0000   *
GLOBAL       90.6398 62 0.0103   *

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

               chisq df      p sig
sex           0.2474  1 0.6189    
age_range  9669.4290  1 0.0000   *
ethnicity     0.0003  1 0.9868    
imd_decile    0.0001  1 0.9940    
icb           1.3258  1 0.2496    
GLOBAL      215.6440 62 0.0000   *

Summary

In the falls cohort the risk of death post-admission:

  • is higher in males.

  • increases with increasing age.

  • up to 28 days those who are Asian/Asian British, Black/Black British, Other or Unknown ethnicity have a lower risk of death compared to White British. In the year post-admission the risk of death is lower for those who are Black/Black British or White Other ethnicities compared to White British.

  • up to 28days is not as clearly correlated with deprivation. However, in the year post-admission risk of death increases with increasing deprivation, those living in the most deprived areas (IMD decile 1) have a higher risk of death than those living in the least deprived areas (IMD decile 10).

  • varies by ICB area. The risk of death in the year post-admission is lowest in the North West London ICB and North Central London ICB areas, and highest in the Gloucestershire ICB and Mind and South Essex ICB areas. In the 28 days post-admission the risk of readmission is lowest in the South East London ICB area, and highest in the Gloucestershire ICB area.

Frail

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

               chisq df      p sig
sex          20.3869  1 0.0000   *
age_range  5270.0670  1 0.0000   *
ethnicity     0.0607  1 0.8054    
imd_decile    0.7662  1 0.3814    
icb           1.1947  1 0.2744    
GLOBAL      341.6358 61 0.0000   *

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

               chisq df      p sig
sex          24.9518  1 0.0000   *
age_range  3124.1412  1 0.0000   *
ethnicity     0.1863  1 0.6660    
imd_decile    0.0331  1 0.8557    
icb           1.4747  1 0.2246    
GLOBAL      531.9057 61 0.0000   *

Summary

In the frail cohort the risk of death post-admission:

  • is higher in males.

  • increases with increasing age.

  • up to 28 days those who are of Unknown ethnicity have a higher risk of death compared to White British. While in the 1 year post-admission the risk of death is lower for those of Asian/Asian British, Black/Black British and Other ethnicities compared to White British.

  • increases with increasing deprivation, those living in the most deprived areas (IMD decile 1) have a higher risk of death than those living in the least deprived areas (IMD decile 10).

  • varies by ICB area. The risk of death in the year post-admission is lowest in the North West London ICB and Dorset ICB areas and highest in the Humber and North Yorkshire ICB and Hereford and Worcestershire ICB areas. In the 28 days post-admission the risk of readmission is lowest in the North West London ICB and Bristol, North Somerset and South Gloucestershire ICB areas, and highest in the Hereford and Worcestershire ICB and Cornwall and Isles of Scilly ICB areas.

Number of deaths on day of admission by ethnicity

For the survival analysis we excluded anyone who died on the day of first admission, so given the differences seen in the risk of death by ethnicity we have checked whether there are differences in the percentage of patients who die on the day of first admission by ethnicity.

Ethnicity

Percentage who die on day of admissions

White British

0.34

Asian/Asian British

0.34

Black/Black British

0.33

Mixed

0.32

Other

0.25

White Other

0.27

Unknown

0.45

The percentage of patient who die on the day of admission is slightly higher for those who are Asian/Asian British and of Unknown ethnicity compared to those who are White British.

Readmissions

Summary of percentage of patients readmitted within 1 year (2022/23)

All admissions are counted an individual events, so some patients with multiple admissions will be included more than once.

Elderly Emergency

Frail

Falls

Sex

female

264,354 (31.2%)

164,982 (29.6%)

21,787 (21.6%)

male

263,236 (37.3%)

171,377 (34.3%)

15,616 (31.2%)

Age

60-64

N/A

N/A

151 (8.4%)

65-69

N/A

24,250 (19.6%)

1,095 (10.4%)

70-74

N/A

40,001 (22.9%)

2,497 (14%)

75-79

122,997 (25.8%)

55,149 (26.9%)

4,537 (17.9%)

80-84

141,841 (31%)

70,137 (32.3%)

7,609 (23.6%)

85-89

144,122 (38.3%)

77,429 (39.3%)

10,227 (29.3%)

90+

118,630 (49%)

69,393 (50%)

11,287 (40.1%)

Ethnicity

Asian/Asian British

11,856 (28.8%)

7,875 (25.6%)

527 (19.6%)

Black/Black British

6,008 (30%)

3,807 (28%)

252 (19.4%)

Mixed

1,185 (30.5%)

843 (29.2%)

74 (22.6%)

Other

5,333 (31.2%)

3,450 (27.3%)

354 (20.3%)

White British

438,842 (34.4%)

278,647 (32.4%)

31,406 (25.4%)

White Other

18,256 (33.2%)

11,552 (31%)

1,279 (23%)

Unknown

46,110 (33.2%)

30,185 (30.3%)

3,511 (22.9%)

IMD decile

1

46,361 (36.5%)

32,300 (32.9%)

3,142 (25.4%)

2

48,872 (35.9%)

33,314 (33.3%)

3,590 (25.9%)

3

49,205 (35.1%)

32,414 (32.4%)

3,576 (25.6%)

4

52,884 (35%)

33,871 (32.6%)

3,661 (25.1%)

5

54,735 (34.2%)

34,818 (32.2%)

3,820 (24.7%)

6

56,492 (33.6%)

35,336 (31.6%)

4,040 (24.7%)

7

56,913 (33.4%)

35,272 (31.6%)

4,001 (24.7%)

8

56,678 (33.1%)

35,110 (31.4%)

3,975 (24.4%)

9

54,924 (32.4%)

33,617 (30.7%)

4,027 (24.7%)

10

50,526 (31.7%)

30,307 (30.1%)

3,571 (23.4%)

Total

527,590 (34%)

336,359 (31.8%)

37,403 (24.8%)

Number of readmissions in 2022/2023

cohort

mean

median

min

lower quartile

upper quartile

max

elderly emergency

0.55

0

0

0

1

67

falls

0.08

0

0

0

0

7

frail

0.31

0

0

0

0

36

The majority of patients have no readmission within a year, and of those that do have a readmission it is most common to just have a single readmission. A small number of patients are having more regular emergency admissions; those with a highest rates appear to be often admitted and discharged on the same day.

Comparing time to readmission between the cohorts using Kaplan-meier plots (2022/23)

Survival analysis was conducted where each admission is treated as an independent event. This means some patients who had multiple admissions within 2022/23 will be included multiple times.

Survival analysis was conducted using a patient’s first admission within 2022/23, so only one event is included per patient, even if the patient has multiple admissions over the year.

The risk of readmission is very similar between the elderly emergency and frail cohorts (note the frail cohort is a subset of the elderly emergency cohort). Those in the falls cohort have a lower risk of readmission.

The risk of admissions is increased slightly by a small subset of patients that have multiple readmissions, as the risk of readmission decreases if only the first admission/ readmission is included for each patient.

Kaplan Meier survival plots of time to readmission (2022/23)

For these plots each admission in 2022/23 was treated as an independent event, meaning that some patients who had multiple admissions within 2022/23 will be included multiple times.

Summary

The risk of readmission is higher in those who are:

  • aged 80-89, compared to those aged 75-79 or 90+.

  • male

  • Asian/Asian British or Black/Black British compared to White British

  • living in a more deprived area

The risk of readmission varies by ICB area, with a lower risk of readmission in the Dorset, Gloucestershire and Cornwall and Isles of Scilly ICB areas and a higher risk in the North West London ICB area.


ICB

Readmissions

No. at risk

Percentage

QR1: NHS Gloucestershire ICB

6,998

15,845

44.2

QT6: NHS Cornwall & Isles Of Scilly ICB

6,206

13,711

45.3

QVV: NHS Dorset ICB

13,829

30,091

46.0

QOC: NHS Shrops, Telford & Wrekin ICB

7,257

15,202

47.7

QGH: NHS Herefords & Worcestershire ICB

10,612

22,144

47.9

QJM: NHS Lincolnshire ICB

11,264

23,504

47.9

QMM: NHS Norfolk And Waveney ICB

15,668

32,669

48.0

QOX: NHS Bath & NE S'set, S'don & W ICB

12,220

25,295

48.3

QJG: NHS Suffolk & North East Essex ICB

15,789

32,004

49.3

QJK: NHS Devon ICB

19,921

40,128

49.6

QNX: NHS Sussex ICB

27,098

54,627

49.6

QE1: NHS Lancashire & South Cumbria ICB

26,021

51,998

50.0

QKS: NHS Kent And Medway ICB

26,752

53,431

50.1

QSL: NHS Somerset ICB

10,398

20,710

50.2

QK1: NHS Leics, Leic'shire & Rutland ICB

13,649

26,907

50.7

QOQ: NHS Humber And North Yorkshire ICB

28,360

55,352

51.2

QWO: NHS West Yorkshire ICB

30,525

59,219

51.5

QT1: NHS Nott'ham & Nottinghamshire ICB

15,900

30,841

51.6

QU9: NHS Bucks, Oxford & Berkshire W ICB

22,738

43,801

51.9

QUY: NHS Bristol, N S'set & S Gloucs ICB

13,351

25,704

51.9

QH8: NHS Mid And South Essex ICB

18,869

36,236

52.1

QM7: NHS Hertfordshire & West Essex ICB

21,674

41,599

52.1

QYG: NHS Cheshire And Merseyside ICB

40,890

78,122

52.3

QMJ: NHS North Central London ICB

12,058

22,830

52.8

QOP: NHS Greater Manchester ICB

37,648

71,233

52.9

QRL: NHS Hampshire And Isle Of Wight ICB

31,835

60,115

53.0

QWE: NHS South West London ICB

15,475

29,159

53.1

QXU: NHS Surrey Heartlands ICB

17,860

33,584

53.2

QHG: NHS Beds, Luton & Milton Keynes ICB

12,699

23,819

53.3

QWU: NHS Coventry And Warwickshire ICB

15,423

28,913

53.3

QUE: NHS Cambs & Peterborough ICB

13,289

24,661

53.9

QJ2: NHS Derby And Derbyshire ICB

19,211

35,321

54.4

QUA: NHS Black Country ICB

21,281

39,069

54.5

QHM: NHS North East & North Cumbria ICB

58,067

106,347

54.6

QHL: NHS Birmingham And Solihull ICB

19,694

35,806

55.0

QNC: NHS Staffordshire & Stoke-On-Tr ICB

21,162

38,497

55.0

QMF: NHS North East London ICB

17,385

30,977

56.1

QF7: NHS South Yorkshire ICB

25,052

44,538

56.2

QPM: NHS Northamptonshire ICB

12,261

21,783

56.3

QKK: NHS South East London ICB

19,908

35,304

56.4

QRV: NHS North West London ICB

27,209

46,491

58.5

Summary

The risk of readmission is higher in those who are:

  • aged over 75 years.

  • male

  • Black/Black British

In this falls cohort there is no clear association between deprivation and risk of readmission.

The risk of readmission varies by ICB area.


ICB

Readmissions

No. at risk

Percentage

QT6: NHS Cornwall & Isles Of Scilly ICB

443

1,253

35.4

QR1: NHS Gloucestershire ICB

571

1,606

35.6

QOC: NHS Shrops, Telford & Wrekin ICB

515

1,340

38.4

QGH: NHS Herefords & Worcestershire ICB

925

2,310

40.0

QJK: NHS Devon ICB

1,380

3,351

41.2

QJM: NHS Lincolnshire ICB

913

2,212

41.3

QK1: NHS Leics, Leic'shire & Rutland ICB

1,025

2,437

42.1

QMM: NHS Norfolk And Waveney ICB

1,543

3,597

42.9

QSL: NHS Somerset ICB

856

1,996

42.9

QOX: NHS Bath & NE S'set, S'don & W ICB

1,168

2,675

43.7

QOQ: NHS Humber And North Yorkshire ICB

2,059

4,685

43.9

QE1: NHS Lancashire & South Cumbria ICB

2,314

5,261

44.0

QVV: NHS Dorset ICB

1,283

2,879

44.6

QJG: NHS Suffolk & North East Essex ICB

1,422

3,170

44.9

QJ2: NHS Derby And Derbyshire ICB

1,169

2,591

45.1

QNX: NHS Sussex ICB

2,675

5,929

45.1

QT1: NHS Nott'ham & Nottinghamshire ICB

1,293

2,831

45.7

QU9: NHS Bucks, Oxford & Berkshire W ICB

1,859

4,043

46.0

QWO: NHS West Yorkshire ICB

2,757

5,866

47.0

QUY: NHS Bristol, N S'set & S Gloucs ICB

1,331

2,796

47.6

QYG: NHS Cheshire And Merseyside ICB

3,413

7,139

47.8

QMJ: NHS North Central London ICB

1,359

2,786

48.8

QOP: NHS Greater Manchester ICB

3,348

6,819

49.1

QKS: NHS Kent And Medway ICB

1,794

3,649

49.2

QM7: NHS Hertfordshire & West Essex ICB

2,077

4,211

49.3

QHM: NHS North East & North Cumbria ICB

4,773

9,638

49.5

QXU: NHS Surrey Heartlands ICB

1,553

3,131

49.6

QUE: NHS Cambs & Peterborough ICB

1,242

2,462

50.4

QHG: NHS Beds, Luton & Milton Keynes ICB

1,360

2,680

50.7

QWU: NHS Coventry And Warwickshire ICB

1,413

2,776

50.9

QH8: NHS Mid And South Essex ICB

2,049

4,018

51.0

QF7: NHS South Yorkshire ICB

2,096

4,061

51.6

QNC: NHS Staffordshire & Stoke-On-Tr ICB

1,522

2,936

51.8

QRL: NHS Hampshire And Isle Of Wight ICB

3,499

6,743

51.9

QUA: NHS Black Country ICB

2,002

3,857

51.9

QWE: NHS South West London ICB

1,661

3,202

51.9

QHL: NHS Birmingham And Solihull ICB

1,586

3,008

52.7

QPM: NHS Northamptonshire ICB

1,086

2,017

53.8

QMF: NHS North East London ICB

2,084

3,863

53.9

QRV: NHS North West London ICB

2,481

4,568

54.3

QKK: NHS South East London ICB

2,701

4,754

56.8

Summary

The risk of readmission is higher in those who are:

  • aged 75-89 years, with those aged under 75 having the lowest risk of readmission

  • male

  • Black/Black British

  • living in the most deprived areas

The risk of readmission varies by ICB area, with a lower risk of readmission in the Gloucestershire and Cornwall and Isles of Scilly ICB areas and a higher risk in the North West London ICB area.


ICB

Readmissions

No. at risk

Percentage

QR1: NHS Gloucestershire ICB

4,148

10,220

40.6

QT6: NHS Cornwall & Isles Of Scilly ICB

3,663

8,823

41.5

QVV: NHS Dorset ICB

8,130

18,927

43.0

QOC: NHS Shrops, Telford & Wrekin ICB

4,462

10,103

44.2

QJM: NHS Lincolnshire ICB

7,376

16,527

44.6

QGH: NHS Herefords & Worcestershire ICB

6,635

14,785

44.9

QMM: NHS Norfolk And Waveney ICB

9,779

21,757

44.9

QOX: NHS Bath & NE S'set, S'don & W ICB

7,496

16,377

45.8

QJK: NHS Devon ICB

11,604

25,029

46.4

QSL: NHS Somerset ICB

6,325

13,593

46.5

QE1: NHS Lancashire & South Cumbria ICB

16,984

36,314

46.8

QJG: NHS Suffolk & North East Essex ICB

9,802

20,893

46.9

QK1: NHS Leics, Leic'shire & Rutland ICB

8,441

18,007

46.9

QNX: NHS Sussex ICB

17,399

37,007

47.0

QKS: NHS Kent And Medway ICB

14,969

31,808

47.1

QOQ: NHS Humber And North Yorkshire ICB

17,588

37,185

47.3

QT1: NHS Nott'ham & Nottinghamshire ICB

10,436

21,526

48.5

QH8: NHS Mid And South Essex ICB

12,217

25,123

48.6

QHG: NHS Beds, Luton & Milton Keynes ICB

7,738

15,858

48.8

QU9: NHS Bucks, Oxford & Berkshire W ICB

14,309

29,297

48.8

QWO: NHS West Yorkshire ICB

20,775

42,578

48.8

QM7: NHS Hertfordshire & West Essex ICB

13,488

27,515

49.0

QOP: NHS Greater Manchester ICB

24,943

50,708

49.2

QYG: NHS Cheshire And Merseyside ICB

28,071

57,082

49.2

QUY: NHS Bristol, N S'set & S Gloucs ICB

8,478

17,189

49.3

QMJ: NHS North Central London ICB

7,702

15,483

49.7

QWE: NHS South West London ICB

10,341

20,598

50.2

QWU: NHS Coventry And Warwickshire ICB

9,928

19,784

50.2

QXU: NHS Surrey Heartlands ICB

11,109

22,127

50.2

QRL: NHS Hampshire And Isle Of Wight ICB

19,659

38,919

50.5

QHM: NHS North East & North Cumbria ICB

37,439

74,048

50.6

QUA: NHS Black Country ICB

13,845

27,287

50.7

QUE: NHS Cambs & Peterborough ICB

8,507

16,773

50.7

QHL: NHS Birmingham And Solihull ICB

12,348

24,058

51.3

QNC: NHS Staffordshire & Stoke-On-Tr ICB

13,845

26,830

51.6

QJ2: NHS Derby And Derbyshire ICB

12,356

23,683

52.2

QF7: NHS South Yorkshire ICB

15,689

29,984

52.3

QMF: NHS North East London ICB

11,399

21,675

52.6

QKK: NHS South East London ICB

13,896

25,951

53.5

QRV: NHS North West London ICB

17,569

32,626

53.8

QPM: NHS Northamptonshire ICB

8,305

15,393

54.0

Multivariate survival analysis of time to readmission (2022/23)

For this analysis we have taken only data from 2022-2023, and only the first admission/time to readmission for each patient.

We have fitted Cox proportional hazard models to our data to assess how various factors independently affect the risk of readmission occurring over time.

For information on the testing of the proportional hazards assumption see Section 1.5.1.

We have used a Cox proportional hazards models and the calculated hazard ratios can be considered as a time-averaged hazard ratio. We have considered models for readmission within 28 days and within 1 yr. There are some differences between the hazard ratios calculated for the two models, but the general trends are consistent.

Elderly emergency

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex          0.1775  1 0.6736    
age_range    0.0000  1 0.9977    
ethnicity    0.2842  1 0.5939    
imd_decile   0.1389  1 0.7093    
icb         23.0542  1 0.0000   *
GLOBAL     584.1550 59 0.0000   *

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex        267.1914  1 0.0000   *
age_range    0.1572  1 0.6918    
ethnicity    0.1140  1 0.7356    
imd_decile   2.0735  1 0.1499    
icb          3.1067  1 0.0780    
GLOBAL     998.7890 59 0.0000   *

Summary

In the elderly emergency cohort the risk of readmission:

  • is higher in males.

  • is higher in those aged 80-89 years compared to those aged 75-79 years. Up to 28 days the risk of readmission in those aged 90+ is no higher than those aged 75-79 years, but in the full year after admission the risk of readmission is higher in those over 90 years than those aged 75-79 years. This may be influenced by the risk of death being significantly different between those aged 75-79 years and those aged over 90.

  • is higher in those who are White British, and significantly lower in those who are Asian/Asian British, Black/Black British, Other or Unknown ethnicity. Up to 28 days those of mixed ethnicity have a similar risk of readmission to White British, but in the analysis, but the risk drops below that of White British in the analysis to 1 year.

  • increases with increasing deprivation, those living in the most deprived areas (IMD decile 1) are more likely to be readmitted than those living in the least deprived areas (IMD decile 10).

  • varies by ICB area. The risk of readmission is lowest in the Cornwall and Isles of Scilly ICB area. In the year post-admission the risk of readmission is highest in South East London ICB and North West London ICB areas. While up to 28 days post-admission the risk is highest in the North East London ICB area.

Falls

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex          2.4394  1 0.1183    
age_range  165.7130  1 0.0000   *
ethnicity    0.0638  1 0.8005    
imd_decile   0.2306  1 0.6311    
icb         10.9718  1 0.0009   *
GLOBAL     109.3977 62 0.0002   *

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex          7.4918  1 0.0062   *
age_range  197.9268  1 0.0000   *
ethnicity    0.0037  1 0.9514    
imd_decile   0.0696  1 0.7919    
icb         18.1754  1 0.0000   *
GLOBAL     113.5035 62 0.0001   *

Summary

In the falls cohort the risk of readmission:

  • is higher in males.

  • is higher in those aged over 70 years compared to those aged 60-64 years.

  • is lower in those of Unknown ethnicity compared to White British. In the analysis to 1 year the risk of readmission is significantly higher in those who are Black/Black British compared to those who are White British.

  • increases with increasing deprivation, those living in the most deprived areas (IMD decile 1) are more likely to be readmitted than those living in the least deprived areas (IMD decile 10).

  • varies by ICB area. The risk of readmission in the year post-admission is lowest in the Cornwall and Isles of Scilly ICB and Gloucestershire ICB areas and highest in the South East London ICB and Northamptonshire ICB areas. In the 28 days post-admission the risk of readmission is lowest in the Gloucestershire ICB and Hereford and Worcestershire ICB areas, and highest in the North West London ICB and Staffordshire and Stoke-on-Trent ICB areas.

Frail

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex          0.8608  1 0.3535    
age_range    1.1072  1 0.2927    
ethnicity    0.3737  1 0.5410    
imd_decile   0.0774  1 0.7809    
icb         97.9359  1 0.0000   *
GLOBAL     503.4398 61 0.0000   *

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

               chisq df      p sig
sex         158.5313  1 0.0000   *
age_range   421.8780  1 0.0000   *
ethnicity     0.1861  1 0.6662    
imd_decile    3.1498  1 0.0759    
icb           3.9549  1 0.0467   *
GLOBAL     1216.2056 61 0.0000   *

Summary

In the frail cohort the risk of readmission:

  • is higher in males.

  • up to 28days age does not significantly influence the risk of readmission.However, in the year post admission the risk of readmission is higher in those aged over 80 years compared to those aged 75-79 years.

  • is higher in those who are White British, and significantly lower in those who are Asian/Asian British, Other and Unknown ethnicity. Up to 28 days those who are Black/Black British also have a lower risk of readmission compared to White British, but the risk is no longer reduced in the analysis to 1 year.

  • increases with increasing deprivation, those living in the most deprived areas (IMD decile 1) are more likely to be readmitted than those living in the least deprived areas (IMD decile 10).

  • varies by ICB area. The risk of readmission in the year post-admission is lowest in the Cornwall and Isles of Scilly ICB and Gloucestershire ICB areas and highest in the South East London ICB and North West London ICB areas. In the 28 days post-admission the risk of readmission is lowest in the Cornwall and Isles of Scilly ICB and Leicester, Leicestershire and Rutland ICB areas, and highest in the Staffordshire and Stoke-on-Trent ICB and North East London ICB areas.

Readmissions- excluding those who died prior to readmission

In the previous analysis of readmissions we see that some of the ICB areas with the lowest readmission rates are those with higher mortality rates. Given that the risk of readmission will be strongly influenced by the mortality rate for this analysis we have excluded all those that died prior to readmission at either 28 days or 1 year. This gives us the risk of readmission for those that survived to the end of the time period of interest, either 28 days or 1 year.

Summary of percentage of patients readmitted within 1 year (2022/23)

All admissions are counted an individual events, so some patients with multiple admissions will be included more than once.

Elderly Emergency

Frail

Falls

Sex

female

131,242 (18.4%)

80,373 (17%)

11,812 (13%)

male

142,128 (24.3%)

91,533 (21.8%)

9,342 (21.3%)

Age

60-64

N/A

N/A

103 (5.9%)

65-69

N/A

14,819 (13%)

751 (7.4%)

70-74

N/A

23,148 (14.7%)

1,592 (9.4%)

75-79

70,287 (16.5%)

30,350 (16.8%)

2,839 (12%)

80-84

76,907 (19.6%)

36,363 (19.8%)

4,533 (15.5%)

85-89

73,095 (23.9%)

37,646 (23.9%)

5,832 (19.1%)

90+

53,081 (30.1%)

29,580 (29.9%)

5,504 (24.7%)

Ethnicity

Asian/Asian British

6,642 (18.5%)

4,327 (15.9%)

352 (14%)

Black/Black British

3,390 (19.4%)

2,136 (17.9%)

178 (14.5%)

Mixed

636 (19.1%)

470 (18.7%)

47 (15.6%)

Other

2,674 (18.5%)

1,689 (15.5%)

203 (12.8%)

White British

229,032 (21.5%)

143,437 (19.8%)

17,877 (16.2%)

White Other

9,826 (21.1%)

6,071 (19.1%)

772 (15.3%)

Unknown

21,170 (18.6%)

13,776 (16.6%)

1,725 (12.7%)

IMD decile

1

24,858 (23.6%)

16,884 (20.4%)

1,861 (16.8%)

2

25,747 (22.8%)

17,167 (20.5%)

2,129 (17.2%)

3

26,021 (22.3%)

16,923 (20%)

2,149 (17.1%)

4

27,271 (21.7%)

17,171 (19.7%)

2,120 (16.2%)

5

28,248 (21.1%)

17,670 (19.4%)

2,069 (15.1%)

6

28,957 (20.6%)

17,937 (19%)

2,259 (15.5%)

7

29,166 (20.5%)

17,786 (18.9%)

2,186 (15.2%)

8

28,932 (20.1%)

17,690 (18.7%)

2,206 (15.2%)

9

28,235 (19.7%)

17,153 (18.4%)

2,209 (15.3%)

10

25,935 (19.2%)

15,525 (18%)

1,966 (14.4%)

Total

273,370 (21%)

171,906 (19.3%)

21,154 (15.7%)

Comparing time to readmission between the cohorts using Kaplan-meier plots (2022/23)

Survival analysis was conducted where each admission is treated as an independent event. This means some patients who had multiple admissions within 2022/23 will be included multiple times.

Survival analysis was conducted using a patient’s first admission within 2022/23, so only one event is included per patient, even if the patient has multiple admissions over the year.

The risk of readmission is very similar between the elderly emergency and frail cohorts (note the frail cohort is a subset of the elderly emergency cohort). Those in the falls cohort have a lower risk of readmission.

The risk of admissions is increased slightly by a small subset of patients that have multiple readmissions, as the risk of readmission decreases if only the first admission/ readmission is included for each patient.

Kaplan Meier survival plots of time to readmission (2022/23)

For these plots each admission in 2022/23 was treated as an independent event, meaning that some patients who had multiple admissions within 2022/23 will be included multiple times.

Summary

The risk of readmission is higher in those who are:

  • older

  • male

  • Black/Black British

  • living in a more deprived area

The risk of readmission varies by ICB area, with a lower risk of readmission in the Dorset, Gloucestershire and Cornwall and Isles of Scilly ICB areas.


ICB

Readmissions

No. at risk

Percentage

QR1: NHS Gloucestershire ICB

6,996

12,987

53.9

QT6: NHS Cornwall & Isles Of Scilly ICB

6,202

11,319

54.8

QVV: NHS Dorset ICB

13,822

25,135

55.0

QOC: NHS Shrops, Telford & Wrekin ICB

7,255

12,678

57.2

QOX: NHS Bath & NE S'set, S'don & W ICB

12,216

21,146

57.8

QJM: NHS Lincolnshire ICB

11,260

19,232

58.5

QGH: NHS Herefords & Worcestershire ICB

10,608

18,096

58.6

QMM: NHS Norfolk And Waveney ICB

15,663

26,465

59.2

QJK: NHS Devon ICB

19,908

33,395

59.6

QKS: NHS Kent And Medway ICB

26,739

44,616

59.9

QJG: NHS Suffolk & North East Essex ICB

15,783

26,316

60.0

QNX: NHS Sussex ICB

27,083

45,150

60.0

QSL: NHS Somerset ICB

10,387

17,198

60.4

QK1: NHS Leics, Leic'shire & Rutland ICB

13,641

22,562

60.5

QE1: NHS Lancashire & South Cumbria ICB

26,013

42,872

60.7

QU9: NHS Bucks, Oxford & Berkshire W ICB

22,719

37,137

61.2

QUY: NHS Bristol, N S'set & S Gloucs ICB

13,341

21,693

61.5

QOQ: NHS Humber And North Yorkshire ICB

28,342

45,751

61.9

QRL: NHS Hampshire And Isle Of Wight ICB

31,818

51,063

62.3

QMJ: NHS North Central London ICB

12,054

19,320

62.4

QT1: NHS Nott'ham & Nottinghamshire ICB

15,894

25,387

62.6

QM7: NHS Hertfordshire & West Essex ICB

21,667

34,584

62.7

QH8: NHS Mid And South Essex ICB

18,864

30,044

62.8

QXU: NHS Surrey Heartlands ICB

17,844

28,416

62.8

QWO: NHS West Yorkshire ICB

30,518

48,521

62.9

QYG: NHS Cheshire And Merseyside ICB

40,866

65,001

62.9

QWE: NHS South West London ICB

15,470

24,527

63.1

QWU: NHS Coventry And Warwickshire ICB

15,407

24,241

63.6

QHG: NHS Beds, Luton & Milton Keynes ICB

12,693

19,941

63.7

QOP: NHS Greater Manchester ICB

37,626

58,834

64.0

QNC: NHS Staffordshire & Stoke-On-Tr ICB

21,155

32,748

64.6

QHL: NHS Birmingham And Solihull ICB

19,686

30,408

64.7

QJ2: NHS Derby And Derbyshire ICB

19,204

29,676

64.7

QUE: NHS Cambs & Peterborough ICB

13,284

20,530

64.7

QHM: NHS North East & North Cumbria ICB

58,035

89,588

64.8

QUA: NHS Black Country ICB

21,268

32,826

64.8

QMF: NHS North East London ICB

17,381

26,344

66.0

QKK: NHS South East London ICB

19,899

30,080

66.2

QPM: NHS Northamptonshire ICB

12,257

18,400

66.6

QRV: NHS North West London ICB

27,200

40,801

66.7

QF7: NHS South Yorkshire ICB

25,041

37,453

66.9

Summary

The risk of readmission is higher in those who are:

  • older

  • male

  • Black/Black British

  • living in a more deprived area

The risk of readmission varies by ICB area.


ICB

Readmissions

No. at risk

Percentage

QT6: NHS Cornwall & Isles Of Scilly ICB

443

1,099

40.3

QR1: NHS Gloucestershire ICB

571

1,326

43.1

QOC: NHS Shrops, Telford & Wrekin ICB

515

1,178

43.7

QGH: NHS Herefords & Worcestershire ICB

925

2,005

46.1

QJK: NHS Devon ICB

1,380

2,927

47.1

QJM: NHS Lincolnshire ICB

913

1,927

47.4

QK1: NHS Leics, Leic'shire & Rutland ICB

1,025

2,119

48.4

QSL: NHS Somerset ICB

856

1,752

48.9

QOX: NHS Bath & NE S'set, S'don & W ICB

1,168

2,379

49.1

QMM: NHS Norfolk And Waveney ICB

1,543

3,114

49.6

QE1: NHS Lancashire & South Cumbria ICB

2,314

4,649

49.8

QVV: NHS Dorset ICB

1,283

2,569

49.9

QOQ: NHS Humber And North Yorkshire ICB

2,056

4,092

50.2

QJG: NHS Suffolk & North East Essex ICB

1,422

2,810

50.6

QJ2: NHS Derby And Derbyshire ICB

1,168

2,295

50.9

QT1: NHS Nott'ham & Nottinghamshire ICB

1,293

2,534

51.0

QNX: NHS Sussex ICB

2,673

5,230

51.1

QU9: NHS Bucks, Oxford & Berkshire W ICB

1,859

3,641

51.1

QMJ: NHS North Central London ICB

1,358

2,557

53.1

QWO: NHS West Yorkshire ICB

2,755

5,161

53.4

QYG: NHS Cheshire And Merseyside ICB

3,412

6,383

53.5

QKS: NHS Kent And Medway ICB

1,794

3,282

54.7

QM7: NHS Hertfordshire & West Essex ICB

2,077

3,785

54.9

QHM: NHS North East & North Cumbria ICB

4,770

8,655

55.1

QOP: NHS Greater Manchester ICB

3,347

6,064

55.2

QXU: NHS Surrey Heartlands ICB

1,553

2,815

55.2

QUY: NHS Bristol, N S'set & S Gloucs ICB

1,331

2,388

55.7

QUE: NHS Cambs & Peterborough ICB

1,242

2,205

56.3

QWU: NHS Coventry And Warwickshire ICB

1,411

2,493

56.6

QWE: NHS South West London ICB

1,660

2,930

56.7

QHG: NHS Beds, Luton & Milton Keynes ICB

1,360

2,396

56.8

QNC: NHS Staffordshire & Stoke-On-Tr ICB

1,522

2,660

57.2

QRL: NHS Hampshire And Isle Of Wight ICB

3,498

6,110

57.3

QH8: NHS Mid And South Essex ICB

2,049

3,546

57.8

QF7: NHS South Yorkshire ICB

2,096

3,610

58.1

QMF: NHS North East London ICB

2,084

3,567

58.4

QUA: NHS Black Country ICB

2,002

3,428

58.4

QHL: NHS Birmingham And Solihull ICB

1,586

2,704

58.7

QRV: NHS North West London ICB

2,481

4,210

58.9

QPM: NHS Northamptonshire ICB

1,086

1,837

59.1

QKK: NHS South East London ICB

2,700

4,392

61.5

Summary

The risk of readmission is higher in those who are:

  • older

  • male

  • Black/Black British

  • living in the more deprived areas

The risk of readmission varies by ICB area, with a lower risk of readmission in the Dorset, Gloucestershire and Cornwall and Isles of Scilly ICB areas.


ICB

Readmissions

No. at risk

Percentage

QR1: NHS Gloucestershire ICB

4,147

8,414

49.3

QT6: NHS Cornwall & Isles Of Scilly ICB

3,659

7,313

50.0

QVV: NHS Dorset ICB

8,126

16,051

50.6

QOC: NHS Shrops, Telford & Wrekin ICB

4,462

8,496

52.5

QJM: NHS Lincolnshire ICB

7,373

13,712

53.8

QOX: NHS Bath & NE S'set, S'don & W ICB

7,495

13,889

54.0

QGH: NHS Herefords & Worcestershire ICB

6,633

12,127

54.7

QMM: NHS Norfolk And Waveney ICB

9,778

17,794

55.0

QJK: NHS Devon ICB

11,597

20,970

55.3

QSL: NHS Somerset ICB

6,322

11,439

55.3

QK1: NHS Leics, Leic'shire & Rutland ICB

8,440

15,202

55.5

QKS: NHS Kent And Medway ICB

14,963

26,619

56.2

QNX: NHS Sussex ICB

17,392

30,885

56.3

QE1: NHS Lancashire & South Cumbria ICB

16,979

30,071

56.5

QOQ: NHS Humber And North Yorkshire ICB

17,578

30,997

56.7

QJG: NHS Suffolk & North East Essex ICB

9,798

17,236

56.8

QU9: NHS Bucks, Oxford & Berkshire W ICB

14,299

25,103

57.0

QHG: NHS Beds, Luton & Milton Keynes ICB

7,735

13,332

58.0

QUY: NHS Bristol, N S'set & S Gloucs ICB

8,474

14,611

58.0

QH8: NHS Mid And South Essex ICB

12,215

21,027

58.1

QM7: NHS Hertfordshire & West Essex ICB

13,482

23,159

58.2

QT1: NHS Nott'ham & Nottinghamshire ICB

10,433

17,896

58.3

QYG: NHS Cheshire And Merseyside ICB

28,057

48,099

58.3

QMJ: NHS North Central London ICB

7,700

13,192

58.4

QXU: NHS Surrey Heartlands ICB

11,105

19,027

58.4

QWO: NHS West Yorkshire ICB

20,767

35,488

58.5

QOP: NHS Greater Manchester ICB

24,933

42,280

59.0

QRL: NHS Hampshire And Isle Of Wight ICB

19,650

33,313

59.0

QWE: NHS South West London ICB

10,336

17,509

59.0

QHM: NHS North East & North Cumbria ICB

37,420

63,183

59.2

QWU: NHS Coventry And Warwickshire ICB

9,917

16,697

59.4

QNC: NHS Staffordshire & Stoke-On-Tr ICB

13,842

23,180

59.7

QHL: NHS Birmingham And Solihull ICB

12,345

20,644

59.8

QUA: NHS Black Country ICB

13,840

23,137

59.8

QUE: NHS Cambs & Peterborough ICB

8,506

14,005

60.7

QRV: NHS North West London ICB

17,561

28,849

60.9

QJ2: NHS Derby And Derbyshire ICB

12,350

20,187

61.2

QMF: NHS North East London ICB

11,398

18,501

61.6

QF7: NHS South Yorkshire ICB

15,685

25,426

61.7

QKK: NHS South East London ICB

13,890

22,250

62.4

QPM: NHS Northamptonshire ICB

8,304

13,109

63.3

Multivariate survival analysis of time to readmission (2022/23)

For this analysis we have taken only data from 2022-2023, and only the first admission/time to readmission for each patient.

We have fitted Cox proportional hazard models to our data to assess how various factors independently affect the risk of readmission occurring over time.

For information on the testing of the proportional hazards assumption see Section 1.5.1.

We have used a Cox proportional hazards models and the calculated hazard ratios can be considered as a time-averaged hazard ratio. We have considered models for readmission within 28 days and within 1 yr. There are some differences between the hazard ratios calculated for the two models, but the general trends are consistent.

Elderly emergency

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex          0.0056  1 0.9405    
age_range    0.0006  1 0.9808    
ethnicity    0.2727  1 0.6015    
imd_decile   0.3531  1 0.5524    
icb         18.0758  1 0.0000   *
GLOBAL     589.8751 59 0.0000   *

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

               chisq df      p sig
sex         145.1689  1 0.0000   *
age_range    62.6748  1 0.0000   *
ethnicity     0.4513  1 0.5017    
imd_decile   13.1561  1 0.0003   *
icb           1.9500  1 0.1626    
GLOBAL     1712.1594 59 0.0000   *

Summary

In the elderly emergency cohort the risk of readmission:

  • is higher in males.

  • increases with increasing age

  • is higher in those who are White British, and significantly lower in those who are Asian/Asian British, Black/Black British, Other or Unknown ethnicity. Up to 28 days those of mixed ethnicity have a similar risk of readmission to White British, but in the analysis, but the risk drops below that of White British in the analysis to 1 year.

  • increases with increasing deprivation, those living in the most deprived areas (IMD decile 1) are more likely to be readmitted than those living in the least deprived areas (IMD decile 10).

  • varies by ICB area. The risk of readmission is lowest in the Cornwall and Isles of Scilly ICB ares. In the year post-admission the risk of readmission is highest in South East London ICB and Northamptonshire areas. While up to 28 days post-admission the risk is highest in the North East London ICB and South East London ICB areas.

Falls

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex          2.1144  1 0.1459    
age_range  212.6728  1 0.0000   *
ethnicity    0.0739  1 0.7858    
imd_decile   0.2586  1 0.6111    
icb          9.3915  1 0.0022   *
GLOBAL     108.7835 62 0.0002   *

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

               chisq df      p sig
sex           0.5675  1 0.4512    
age_range  3917.5227  1 0.0000   *
ethnicity     0.0291  1 0.8646    
imd_decile    0.2145  1 0.6433    
icb           8.1775  1 0.0042   *
GLOBAL      131.4397 62 0.0000   *

Summary

In the falls cohort the risk of readmission:

  • is higher in males.

  • is higher in those aged over 70 years compared to those aged 60-64 years.

  • is lower in those of Unknown ethnicity compared to White British. In the analysis to 1 year post-admission the risk of readmission is also significantly lower in those who are Asian/Asian British or from Other ethnic backgrounds.

  • increases with increasing deprivation, those living in the most deprived areas (IMD decile 1) are more likely to be readmitted than those living in the least deprived areas (IMD decile 10).

  • varies by ICB area. The risk of readmission in the year post-admission is lowest in the Cornwall and Isles of Scilly ICB and Gloucestershire ICB areas and highest in the South East London ICB and Northamptonshire ICB areas. In the 28 days post-admission the risk of readmission is lowest in the Leicester, Leicestershire and Rutland ICB and Hereford and Worcestershire ICB areas, and highest in the North West London ICB and Staffordshire and Stoke-on-Trent ICB areas.

Frail

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

              chisq df      p sig
sex          0.4717  1 0.4922    
age_range    4.4920  1 0.0341   *
ethnicity    0.4003  1 0.5269    
imd_decile   0.2156  1 0.6424    
icb         78.1128  1 0.0000   *
GLOBAL     510.2711 61 0.0000   *

Forest plot of hazard ratios. Black indicates no significant difference compared to the reference group, red indicates a significant increase in the hazard ratio (risk) and green indicates a significant decrease. The size of the point gives an indication of the relative number of people in each group.

               chisq df      p sig
sex         105.3108  1 0.0000   *
age_range  6502.4524  1 0.0000   *
ethnicity     0.6414  1 0.4232    
imd_decile   13.6494  1 0.0002   *
icb           1.4058  1 0.2358    
GLOBAL     2154.9872 61 0.0000   *

Summary

In the frail cohort the risk of readmission:

  • is higher in males.

  • increases with increasing age.

  • is higher in those who are White British, and significantly lower in those who are Asian/Asian British, Black/Black British, Other and Unknown ethnicity. In the analysis to one year post-admission those who are White Other also have a significantly lower risk of readmission.

  • increases with increasing deprivation, those living in the most deprived areas (IMD decile 1) are more likely to be readmitted than those living in the least deprived areas (IMD decile 10).

  • varies by ICB area. The risk of readmission in the year post-admission is lowest in the and Gloucestershire ICB and Cornwall and Isles of Scilly ICB areas and highest in the South East London ICB and Northamptonshire ICB areas. In the 28 days post-admission the risk of readmission is lowest in the Cornwall and Isles of Scilly ICB and Leicester, Leicestershire and Rutland ICB areas, and highest in the Staffordshire and Stoke-on-Trent ICB and North East London ICB areas.

Conclusions

Following an emergency admission the risk of both death, and readmission (in those who do not die within the follow-up period), in all 3 cohorts (elderly emergency, falls or frail) was higher for males, those living in more deprived areas and those who were older at admission.

There was also significant variability in risk of death and readmission between ICB area, even once any differences in the age, ethnicity, sex and deprivation of the areas were accounted for in this analysis.

The risk of death in the year post-admission was lower for those who were Asian/Asian British, Black/Black British or Other ethnicities, compared to White British. There is a general trend towards a higher risk of readmission for those who are White British than those of other ethnicities. In the elderly emergency and frail cohorts the risk of readmission was lower in those who were Asian/Asian British, Black/Black British, Other and Unknown ethnicity. For the falls cohort there are less differences between ethnic groups, but in the 1 year post-admission analysis the risk of readmission is also significantly lower in those who are Asian/Asian British, from Other or Unknown ethnic backgrounds.